Policy makers and regulators have placed a great emphasis on venous thromboembolism (VTE) prevention due to its significant healthcare burden. Hospital VTE measures are now part of CMS’s pay-for-performance and Joint Commission regulatory programs. Despite the existence of effective preventive treatments for VTE, prophylaxis rates among medical patients have been reportedly low. Few studies have looked at the effectiveness of these interventions in electronic health record (EHR) environments. As more hospitals implement EHR systems, it is critical to define the strengths and limitations of such decision support tools to optimize patient safety. Assessing Computerized Decision Support My colleagues and I had a study published in the Journal of Hospital Medicine that evaluated the safety and effectiveness of a computerized decision support application. Our VTE decision support module was comprised of order sets with the following features: • Patients were identified as being on the medicine service based on admitting service designation. • An order set offered pharmacologic VTE prophylaxis options or alternate options to document the lack of clinical indications for pharmacologic VTE prophylaxis, planned therapeutic anticoagulation, or contraindications to VTE prophylaxis. • Alternate order sets were offered with mechanical VTE prophylaxis options if physicians indicated that pharmacologic VTE prophylaxis was contraindicated or if the information system identified a contraindication. • If pharmacologic VTE prophylaxis was not prescribed, these rules were repeated every 5 days. The decision support intervention was put into place on medicine services, and its effectiveness and safety were assessed in comparison with non-medicine comparison services (in which the intervention was not deployed). Following intervention, there was a significant increase in the rate of overall and...

Studies have shown that using tPA within 3 hours of stroke onset raises the chances for good outcomes in some patients who suffer one of these events, but this treatment is often underused. Although more than 11% of patients with stroke are eligible to receive tPA, studies show that 2% or less receive these important thrombolytics. Eliminating delays in the recognition and response to signs and symptoms of stroke could increase the proportion of tPA-eligible patients to as high as 24%. Designated stroke centers have improved the delivery of tPA, but less than one-quarter of patients in the United States live within 30 minutes of one of these centers. “The importance of early treatment for stroke cannot be overstated,” says Phillip A. Scott, MD. “Because of the short treatment window in which tPA can be given, many patients seek treatment at local community hospitals.” Unfortunately, neurologists are frequently unavailable for acute stroke care in community EDs. Furthermore, ED physicians often are hesitant to use thrombolytics due to time and resource issues or lack of experience with tPA. The INSTINCT Trial Few randomized controlled trials have tested practical interventions to increase tPA delivery for stroke patients in community hospitals. Identifying successful interventions could improve stroke care and serve as a model to enhance the adoption of other high-risk treatments. In an effort to increase tPA use in community hospital settings, the Increasing Stroke Treatment through Interventional Change Tactics (INSTINCT) trial was initiated in Michigan. The goal of INSTINCT was to assess the ability of a multilevel, barrier assessment-interactive educational intervention to increase tPA use in community hospitals, explains Dr. Scott,...

A Canadian study has found that vascular and bleeding complications following percutaneous aortic valve replacement (PAVR) appear to be markedly reduced with careful patient selection, advanced interventional techniques, and a fully percutaneous procedure. Vascular complications following PAVR occurred most often if: The external sheath diameter was larger than the minimal artery diameter. Moderate or severe calcification existed. Patients had peripheral vascular disease. Abstract: Journal of the American College of Cardiology, January 10,...

More than 1 million cardiac catheterizations are per­formed in the United States annually, and most of these procedures are performed via the femoral arter­ies through the groin. With transfemoral catheterization, patients must lie flat for 4 to 6 hours after the procedure. This is necessary to ensure the puncture site reaches hemostasis and to prevent bleeding complications. Transfemoral cath­eterization can be painful for patients once the procedure is completed because there is a need to compress the artery for 20 minutes manually. The decreased mobility after the proce­dure can also lead to other problems during hospitalization. An alternative approach that is being used by more and more clinicians nationwide is transradial catheterization. In these procedures, the coronary arteries are accessed via the wrist, enabling patients to become mobile almost immediately after the procedure. After the surgery, patients can walk, sit upright, use the bathroom, and eat and drink more quickly than with the transfemoral approach. The transradial approach has also been associated with lower complication rates and increased patient comfort. The complication rate for the transfemoral approach varies but can be as high as 3% to 5%. For transra­dial approaches, the rate drops to less than 1%. In addition, the bleeding associated with transfemoral approaches can be more dangerous than for that of transradial procedures. History of Transradial Catheterization The first transradial diagnostic catheterization was per­formed in the late 1980s in Europe. In 1993, a research team in Amsterdam began using the technique for interventional procedures. In recent years, the methods for catheterization have become increasingly enhanced. Some interventional cardiologists view transradial catheterization as the optimal choice for a...